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If there’s one perfectly safe conclusion to draw from nearly a century of public health research, it’s this: Cigarette smoking is really, really bad for your health. An unusually complete, if rather obvious, 2010 Surgeon General’s Report on the topic shows that inhaling tobacco smoke not only causes lung disease but also leads to increased risks of stroke, heart attack, and dozens of other maladies. As a result, it’s not surprising that 38 states (sin-happy Nevada among them) and countless localities have enacted various smoking bans while advertisements, public health campaigns, and tax policies send a simple message: Smokers must quit all tobacco use or die early, painful deaths.

AP Images

But public health crusaders haven’t stopped at fighting smoking: Bans on smokeless tobacco use, e-cigarettes, and outdoor smoking have gone into force in locations ranging from the University of Texas’s Arlington Campus (all tobacco), to Boston (e-cigarettes). A growing body of research, however, reveals that the shun-tobacco-or-die dichotomy is an oversimplification. In fact, there’s significant evidence that the act of inhaling burning plant matter does much of the harm while the addictive substance in question (nicotine) and the plant itself (tobacco) are a mixed bag. Public health policy may be better served by a harm reduction strategy that continues efforts to discourage smoking while trying to steer tobacco and nicotine users towards safer forms of the substances.

A review of the evidence should start with nicotine. Like other stimulants, it potentially causes long-term cardiovascular harm by increasing one’s heart rate and, without a doubt, is addictive for at least a portion of the population. However, peer-reviewed research also shows that nicotine improves focus and alertness, and decreases appetite (hence the weight gain associated with quitting smoking). And the relationship between nicotine and cancer is complicated: It doesn’t necessarily cause cancer in humans but some animal studies indicate it could potentially promote tumor growth.

In some cases, nonetheless, the benefits of nicotine use may outweigh the harms. Schizophrenics, for example, smoke at up to four times the rate of the population as a whole, and a significant, well-regarded body of research suggests that smoking is a form of self-medication to control their condition. (States including Connecticut, Maryland, and Pennsylvania specifically exempt mental hospitals from smoking bans.) And nicotine gum seems as effective as anything else in helping smokers avoid weight gain after they quit.

Despite the manifest harm of cigarette smoking, it’s surprisingly hard to find strong evidence linking nicotine or tobacco per se to serious negative health outcomes. Certain formulations of smokeless tobacco, particularly Swedish-style snuff, snus, that’s held under the lip rather than chewed, appear to produce cancer rates only a bit higher than those in the population as a whole. (Other forms of smokeless tobacco—mostly forms consumed outside of the United States—can be nearly as bad as cigarettes.) To be sure, tobacco isn’t a health food and its repeated use in any common form will probably increase cancer prevalence somewhat. But it’s pretty clear that the way one consumes tobacco matters a lot.

Indeed, the real harm appears to stem from the inhalation of thousands of compounds—several hundred of them identified as toxic—contained in burning plant matter. Brad Rodu, an oral cancer specialist at the University of Louisville who holds an endowed chair in tobacco harm reduction research, puts it well: “I love coffee and I’m sure I could get my caffeine if I smoked my coffee beans,” he says. “But I would be paying a much different price in overall health if I were consuming caffeine that way instead of in a water soluble mix.”

This leads to a strong case for a different way of looking at nicotine. The burgeoning official hostility to devices like the e-cigarette, which delivers aerosolized nicotine to users who would otherwise be smoking, is unwarranted. While broadly discouraging cigarette smoking will promote better public health, trying to end all use of tobacco and nicotine is a fool’s errand. A sizable majority of the U.S. population—median age 37—has grown up in a world where public health officials have always offered stern warnings about the consequences of tobacco use, where “good guys” in current movies have never smoked, and where most indoor public places outright ban smoking. But over a fifth of the population nonetheless smokes. And quitting is hard. No given method of smoking cessation works reliably for more than about 8 percent of smokers.

Unless the United States seriously wants to legislate an all-out tobacco prohibition, the easy public health victories achieved by reducing smoking (prevalence has fallen by almost half since the surgeon general issued the first stern warnings about it in the early 1960s) may have mostly been won, as the “hard core” smokers find themselves unable to quit and thus go to their graves sucking on cancer sticks.

Thus, for at least some people, some of the time, less harmful ways to get nicotine deserve attention from public health authorities. Anecdotal evidence shows that it might work. The country with the lowest smoking-related cancer and cigarette smoking rates for men in the Western world, Sweden, also has the highest rates of smokeless tobacco use. People who use snus, nicotine gum, or lozenges as a replacement for cigarettes, likewise, see many of the same short-term positive health benefits as those who quit tobacco use altogether. (Longer-term trends look promising, too, but, as with any public health issue, the data are incomplete.)

Public health strategies that continue to discourage smoking while accepting and, in certain cases, even promoting the use of other tobacco or nicotine products deserve a try. In fact, Rodu and some others are trying just this in Owensboro, Kentucky. (Results won’t be available for a few years.) Absent significant evidence to the contrary, efforts that ban the use of all tobacco/nicotine products—particularly those that appear less harmful than cigarettes—may well do more harm than good.

Public health should never promote tobacco use for those who don’t already use it, but it should be welcoming to the idea that some forms of tobacco are less harmful than others. Americans will never stop smoking altogether, and truly safe tobacco use is impossible. But strategies that try to direct smokers towards less harmful alternatives could save lives.